All nations

Make end-of-life care available for people in all nations, especially the poorer countries.

Even in economically underdeveloped countries the palliative care approach can prevent and address suffering. Making oral morphine available is the top end-of-life priority in Africa; whereas high income countries can learn from Africa about how psychological, social and spiritual support can be better provided, and even about the value of innovative technologies.

Comparing Scotland and Kenya

As primary care is the only level of care available to most people in less developed countries, its potential must be maximised and enhanced, ideally by international collaborations to let end-of-life care reach most people there. Having completed a study in Scotland of people dying with lung cancer, we took the opportunity to do a similar study with colleagues in Kenya.(1) We asked the same questions in Scotland and in Kenya to people at home "what are the main problems that you are facing just now?" and compared the findings.

• In Scotland the main issue that people would mention first was existential, leading to spiritual distress, whereas in Kenya the main issue was that of physical suffering, especially pain.
• In Scotland analgesia was effective and affordable, but in Kenya it was unaffordable and largely unavailable.
• In Scotland people felt anger in the face of the illness whereas in Kenya there was greater expression of acceptance.
• In Scotland someone might say "I'll just keep it to myself" but in Kenya there was community support and engagement which was accepted by patients.
• In Scotland the spiritual needs were evident but unmet while in Kenya patients were comforted and inspired by their belief in God.
• In Scotland diagnosis brought active treatment but in Kenya it signalled waiting for death.

This comparison indicates that communities in rural Africa can provide effective end-of-life care in all dimensions apart from the physical, whereas in the UK needs in non-physical dimensions are less well met. In Africa only 4 countries have palliative care services integrated within their national health services, but most countries have vibrant communities where members visit the dying to comfort and support them practically. Economically developed countries can learn much from talking about death and dying and visiting people, and supporting our friends and neighbours in the community at the end-of-life.

References

1. Murray SA, Grant E, Grant A, Kendall M. Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers. BMJ 2003;326:368-72